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Top tips: acne

Read this article to learn more about:

identifying those who are at greatest risk of severe acne

why some patients may show poor response to treatment

why monotherapy with antibiotics should be avoided.

This top tips article on acne management is based on a combination of different resources, and focuses on primary care management only, with onward referral to secondary care. In the UK, approximately 3% of GP consultations with patients aged 13–25 years are related to acne.1 In 2000, UK GPs wrote 2.6 million prescriptions for acne, which included 0.7 million prescriptions for topical antibiotics, and 1 million for oral tetracyclines.2

1 Make the correct diagnosis-identify high-risk patients

Early diagnosis and careful clinical assessment of acne can help to deliver best practice in a number of ways. Some patients will be destined to develop more severe disease and/or respond less well to treatment. It is important that primary care clinicians recognise poor prognostic factors:3

early age of onset for acne in both sexes; and in girls, relatively earlier menarche and higher levels of dehydroepiandrosterone

early presentation with mid-facial lesions, predominantly comedones

marked seborrhoea (greasy skin)

truncal acne

strong family history of acne and/or scarring

development of scarring

psychological issues as a result of acne.

A careful history and examination will identify at-risk individuals. Assessment and recognition of specific lesions and the degree of seborrhoea will inform management and selection of therapies that target the specific clinical presentation as well as aetiological factors. Acne is associated with an increased likelihood of psychiatric morbidity so it is important to assess mental status.4 Early intervention and counselling may reduce mental health decline and the isolation associated with acne.5

2 Understand the pathogenesis in order to tailor treatment

The pathogenesis of acne is complex and centres on the pilosebaceous unit.

Factors involved in the pathophysiology include:6,7

an androgen-dependent increase in sebum production

abnormal follicular differentiation with hyperkeratinisation within the intrafollicular duct

early peri-follicular inflammation prior to any microbial colonisation

later inflammation as a result of P. acnes colonisation; this is characterised by a cell-mediated immune response.

3 Know the basics of common topical therapies

The British National Formulary8 has over 20 different acne treatments, but making a rational choice is difficult because of a limited evidence base.8 For further information on the use of topical therapies, see the PCDS Acne-primary care treatment pathway (Figure 1, below).9

5 Warn patients of side-effects of retinoids9

In most cases, topical retinoids will irritate the skin when first applied. Practitioners should ensure that they warn patients of this side-effect, as some patients may stop treatment due to the unexpected irritation and skin dryness.

Patients should be encouraged to first cleanse the skin, and then apply a small amount of the retinoid, avoiding the eyes and lips. The retinoid should be left on for 15–30 minutes, and then washed off and moisturiser applied.10 The patient should slowly increase the time the retinoid is left on the skin to build tolerance, ultimately aiming to leave the retinoid on overnight. The patient will know the retinoid is effective when the skin loses it shine; however, it may take 6 weeks from start of treatment for the acne formation to decrease. A similar approach can be taken when using benzoyl peroxide topically.

6 When to refer

Most individuals with acne can be managed in primary care. NICE advises referral to a specialist service if a patient:5

has a very severe variant such as fulminating acne with systemic symptoms (acne fulminans)

has severe acne or painful, deep nodules or cysts (nodulocystic acne) and could benefit from oral isotretinoin

has severe social or psychological problems, including a morbid fear of deformity (dysmorphophobia)

is at risk of, or is developing, scarring despite primary care therapies

has moderate acne that has not responded to treatment, which should include several courses of both topical and systemic treatment over a period of at least 6 months; failure is probably best based on a subjective assessment by the patient

is suspected of having an underlying endocrinological cause for the acne that needs assessment.

7 Take a stepwise approach

Often it is difficult to know where to start with acne treatments. First, you should decide if the acne is comedonal predominant or pustular/nodular predominant. Second, consider whether the acne covers a small area such as the chest or face, which can be treated topically, or if it is widespread and not practical to treat topically. See Figure 2 (below).11

Figure 2: Acne treatment ladder11

* Patients may wish to start treatment 2–3 evenings per week and gradually increase the frequency and duration of applications

8 Avoid monotherapy with antibiotics

Oral antibiotics in acne must only be used when indicated and should never be used as monotherapy because of the increasing emergence of antibiotic resistance. Oral antibiotics are indicated for patients with extensive disease, which includes truncal acne and moderate to severe papulopustular acne.12

Antibiotics commonly used for acne are shown in Figure 2 (above).11 Doxycycline and lymecycline should be selected in preference to minocycline and oxytetracycline because they have a superior side-effect profile and result in better patient adherence to therapy.13 Benzoyl peroxide should be used alongside antibiotics to reduce the likelihood of bacterial resistance emerging.7

Antibiotics are essential for maintenance and treatment of some patients with acne but should be reviewed every 2–3 months. Many patients' symptoms will clear in 3 months but some may require life-long antibiotic treatment.

Some of the benefits of using antibiotics comes from the anti-inflammatory effects, rather than the antimicrobial effects alone.14

9 Consider hormonal therapy

Hormonal therapies can be a useful option in the management of acne in women. All combined oral contraceptives (COC) have the potential to reduce acne through their oestrogenic effects.15 One cyproterone acetate/ethinylestradiol preparation has a licence for the treatment of severe acne, but is not licensed as a contraceptive agent in the UK.16

Third-generation COCs contain less androgenic progesterone (e.g. gestodene, desogestrel), but have an increased risk of venous thromboembolism (VTE) compared with second-generation pills containing progesterone (e.g. levonorgestrel). The risk of a VTE is highest for first-time users and during the first year a woman uses the combined pill.17

Careful selection and counselling of patients is required when prescribing a COC for acne, and healthcare professionals should be mindful of the adverse effect profile.

Retinoids are not recommended in pregnancy due to teratogenicity and therefore patients should ideally be on contraception if sexually active. The combined pill offers a potentially beneficial effect on acne whereas progesterone only contraception (e.g. progesterone only pill, contraceptive implant) may worsen acne.15

Current advice from the Faculty of Sexual and Reproductive Healthcare states that no additional contraception is needed during or after a course of non-enzyme inducing antibiotics (NB rifampicin is an enzyme inducer).18

10 Direct the patient to useful resources

Patients who come to see you about their skin have usually tried over-the-counter medications and researched online. Some useful resources to direct patients to include:

Acne Academy—a website developed by Harrogate Hospital, which has helpful myth busters and advice for patients as well as parents